After the closing ceremonies of this summer's annual meeting of the Wilderness Medical Society, nearly 400 participants from around the world returned home from Telluride, Colorado to places like Boulder and Anchorage, Chamonix and Kathmandu. I returned to New York City, where I practice emergency medicine and wilderness medicine right in Manhattan.

Back home, I politely tolerate the jokes about duct tape and rubbing sticks together to make fire. But then I quietly gloat in my perfect little niche—wilderness medicine in the big city, where it really matters.

Modern wilderness medicine dates back to the great expeditions of the 1800s. Before beginning their epic journey, Lewis and Clark sought medical training from Benjamin Rush, the premiere physician of the day (and traveled with essentials such as pulverized rhubarb and tincture of opium). During the brutal winter of 1812, Napoleon’s surgeon general Dominique Jean-Larrey described the pathophysiology and treatment of frostbite as the French retreated from the Russian front. His methods for treating cold injury remained widespread until the post World War II era.

And in 1981, groundbreaking physiologist John West led a medical expedition to Mt. Everest, bringing the science of altitude medicine into the modern era with a series of experiments that redefined human performance at altitude.

Unfortunately for me, the highest point in New York City is Staten Island's Todt Hill, at a lofty elevation of 401 feet (I haven’t summited...yet). But wilderness medicine doesn’t just mean remote or mountainous: it means environmental conditions from heat stroke to hypothermia, austere settings like disasters, and environmentally transmitted infections like Lyme disease and even rabies (not to mention Zika).

Sometimes it’s obvious—patients bring the backcountry with them. Aside from the tick-borne diseases that weekenders import from upstate hiking trips, I’ve used my ‘wilderness’ knowledge diagnosing the likes of high altitude pulmonary edema in trekkers (Machu Picchu to JFK) and decompression sickness in divers (Caribbean scuba trip to JFK). A colleague of mine and I recently headed straight for the standard wilderness medicine textbook for some tips on removing a barbed fishhook from the finger of an unlucky urban angler.

We’ve got heat and cold here too. Between 2000 and 2012, 162 deaths in the city were blamed on excessive heat. And a recent study by researchers at Columbia’s Earth Institute suggested that given current emission levels, New York’s number of annual heat deaths could rise into the thousands. An aging population more susceptible to heat stroke and dehydration means that emergency departments like mine will see more of these conditions.

And infectious diseases? For sure. This summer, the NYC Department of Health ramped up its campaign to educate residents and health professionals about the growing prevalence of Lyme disease within city limits, and even raised the concern that deadly Rocky Mountain spotted fever might surface in the city as well. So the wilderness is encroaching upon us whether we like it or not.

But more than all that, it’s about mindset. Wilderness medicine in the city is different from just another day in the emergency department because sometimes, whether because of a computer system failure (frequent) or a natural disaster (rare), we need to rely on the skills and attitudes that make wilderness medicine special: a knack for improvisation, smart resource allocation, and a keen awareness of the big picture.

The attitude pays off when casualties from events like building explosions arrive a dozen at a time. Or when the lights in Manhattan go out, as they did for two ninety-plus degree days in August 2003, when my fellow interns and I improvised communications systems, cooling treatments for heat stroke, and emergency care for an influx of patients in a sweaty ER. As a teacher, I focus on those special skills and attitudes constantly, since they’re critical regardless of where or how my students will eventually practice medicine.

Sometimes, the front-country becomes the backcountry. Most of the Rockaways and Jersey Shore after Hurricane Sandy qualified as a resource-limited wilderness. Experts predict that we’ll be seeing a greater frequency of extreme weather events in the future. Over the past century, sea levels in the city have risen and water levels during floods are higher than ever. As these trends continue, we’ll need medical providers (and teachers) who can prepare for the enormous effect on the public health that will follow.

In our most dire moments, after the September 11th attacks in 2001, Outside Magazine reported on the contributions of wilderness practitioners at the World Trade Center site. Cave rescue specialists made their way through the rubble, and a logistics specialist from Oregon told the magazine, “Never in my entire life did I think I’d be standing in New York City in a Forest Service uniform.”

Sure I love duct tape. Who doesn’t? Works great for blisters. But wilderness medicine matters because the environment’s role in human health matters. As the health effects of climate change become more common in cities like ours, and as we face increasing numbers of disasters and other events that overwhelm our medical system, clinicians who can negotiate this common ground will become essential whether they’re practicing in the big city or on a mountaintop.

Here in New York, there’s no easy access to 14,000 foot peaks, backcountry skiing, or gnarly whitewater. So as a wilderness medicine doctor, that stinks for me. But here’s what I do have: a global, mobile population in a city that regularly experiences frigid lows and blistering highs, natural and manmade disasters, and the wrath of nature.

This all might prompt wary urbanites to run for cover at the local theatre or cocktail lounge, and avoid the outdoors altogether. But the point is the opposite -- go outside! Wilderness medicine in the city is a great niche because of our rich and diverse local environment. So my fellow New Yorkers should enjoy the hiking and climbing, skating and swimming, balmy summers and invigorating winters in the five boroughs.

Just don’t forget your rhubarb and watch out for heat stroke, frostbite, and of course, rabid raccoons.